Your guide to prescription drug coverage for your patients
Get a current list of pharmacies in the Community Health Plan of Washington (CHPW) network and find out which drugs are on the formulary:
Important: The formulary and search do not apply to Medicare Advantage Plan members. Please refer to the CHPW Medicare Advantage website for information on Medicare Plan coverage.
Changes Coming to 2020 Formulary
On January 1, 2020, all managed care plans and Apple Health fee-for-service programs will continue to phase in a Single Preferred Drug List (PDL).
This change is mandated by the Washington State Legislature.
The Health Care Authority is working with managed care plans that serve Apple Health clients to create the Apple Health PDL. Managed-care plans will continue to use their own preferred drug lists for drugs not included in the Apple Health PDL.
Please contact [email protected] with any questions.
To request a prior authorization, step therapy, nonformulary, or quantity limit override, please call ESI at 1-844-605-8168, 24 hours a day, 7 days a week, and speak to a prior authorization service specialist. This specialist will review medical information and criteria with the provider or designee regarding the need for the requested drug.
Any pharmaceutical not listed on our formulary requires prior authorization. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use https://www.CoverMyMeds.com to start the prior authorization process.
You can submit a request for a coverage determination review by sending in a Coverage Determination Request form or filling out the online form.
Pharmacy Reimbursement Issues
If you are having an issue with reimbursement, please submit an inquiry to ESI through their Pharmacist Resource Center.
Pharmacy Emergency Fills
Emergency fills may be covered to prevent interruptions in therapy during an emergency. View our policy on emergency fills.
Carved out drugs: Covered by Fee-for-Service
- Axicabtagene ciloleucel (Yescarta)
- Brexucabtagene autoleucel (Tecartus)
- Burosumab-twza (Crysvita)
- Cerliponase alfa (Brineura)
- Crizanlizumab-tmca (Adakveo)
- Edavarone (Radicava)
- Elapegademase (Revcovi)
- Emapalumab-lzsg (Gamifant)
- Eterplirsen (Exondys 51)
- Givosiran (Givlaari)
- Golodirsen (Vyondys 53)
- Luspatercept-aamt (Reblozyl)
- Lutetium Lu 177 dotatate (Lutathera)
- Nusinersen (Spinraza)
- Onasemnogene abeparvovec (Zolgensma)
- Pegvaliase-pgpz (Palynziq)
- Risdiplam (Evrysdi)
- Tisagenlecleucel-t (Kymriah)
- Triheptanoin (Dojolvi)
- Viltolarsen (Viltepso)
- Voretigene neparvovec-rzyl (Luxterna)
- Hepatitis C medication
- Hemophilia treatment
The Washington State HCA will be responsible for ALL pre-authorizations and approvals for therapy based on HCA clinical guidelines. HCA Policy is available here.
Medications available for 90-day fills
CHPW covers 90-day supplies for most chronic medications. Ask your physician or pharmacist for a 90-day supply of your medications at your next visit.
Personal Medication Coach Program
The Personal Medication Coach Program works with doctors and patients to ensure that medications are effective and being used correctly.
The Personal Medication Coach Program is a service for members with multiple health conditions and who take multiple medications. This program is offered through a partnership between CHPW and MedWiseRx.
- MTM Provider Credentialing Checklist
- MTM Provider and Member Requirements
- Sample MTM form (for assistance in guiding medication therapy review)
If you are looking for Medication Therapy Management for a Medicare Advantage member, visit the CHPW Medicare Advantage website for information on Medicare Medication Therapy Management information.
Patient Review and Coordination Program
Our Patient Review and Coordination (PRC) Program helps members use their medical services safely and appropriately.
Members who are selected for PRC must choose one primary care provider, pharmacy, and hospital. One primary care provider makes sure medical care and prescriptions are coordinated for the health and safety of the member.
To refer a patient to the PRC program or learn more, call us at 1-866-907-1902.
Second Opinion Program
As mandated by the legislator in RCW 74.09.490, HCA has developed the second opinion program to improve prescribing practices in children.
In collaboration with The Pediatric Mental Health Advisory Group and the Drug Utilization Review Board, HCA has established pediatric mental health guidelines to identify children who may be at high risk due to off-label use of prescription medication, use of multiple medications, high medication dosage, or lack of coordination among multiple prescribing providers.
- Apple Health Second Opinion Program Frequently Asked Questions
- Second Opinion Review Process (SON) Flowchart
Partnership Access Line (PAL)
To assist prescribers in meeting the needs of children with a mental health diagnosis, and to minimize the need for required SON review, providers can contact the Partnership Access Line (PAL). PAL is a telephone based child mental health consultation system funded by the state legislature, being implemented in Washington State. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver consultation services. The PAL team is available to any primary care provider throughout Washington State.
PCPs may call 1‐866‐599‐7257 between 8am and 5pm for any type of mental health issue that arises with any child, not just CHPW members. For additional information on the PAL visit Seattle Children’s website.
Pharmacy and Therapeutics (P&T) Committee
Our P&T Committee meets to evaluate our formulary, prior authorization requirements, and safety measures to ensure quality. Read the most recent decisions:
- November 15, 2019: No Clinical Decisions
- June 20, 2019: No Clinical Decisions
- March 25, 2019: No Clinical Decisions
- November 14, 2018: No Clinical Decisions
- July 13, 2018: No Clinical Decisions
- March 2, 2018: No Clinical Decisions
Be sure to read the latest Drug Recall Report for updates on medications that are recalled due to safety issues.